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We remove a tooth when it cannot be saved, or when saving it would not last long enough to be worth doing. Many teeth that look lost can be kept with a root canal, a crown or gum treatment, and keeping the tooth is our preference. When extraction is right, it is a straightforward procedure under local anesthesia in the office, and the main decisions are about the space afterward: an implant at the same visit, a bone graft to keep the implant option open, or no graft if the tooth will not be replaced. Wisdom teeth have their own page.
Why teeth are removed
- Decay that has destroyed too much of the tooth to rebuild
- A crack running below the gum line that no crown can contain
- Advanced gum disease that has cost the bone around the tooth
- A root canal that has failed and cannot be retreated
- An infection that will not resolve while the tooth remains
- A tooth so broken down that any repair would be short-lived
- Occasionally, a tooth removed to make room for orthodontic treatment, or a baby tooth that never fell out
In each case the question is whether the tooth can be made sound and kept, and for how long.
Save it, remove it or leave it
Before any tooth is removed, we go through the alternatives: gum treatment, a root canal, a crown, whatever applies. Sometimes there are real options. Sometimes the tooth has too little left and treatment would only buy a short time. You can also choose to leave a damaged tooth alone, though if it is painful or infected that is rarely a good choice.
Not every extracted tooth needs replacing:
- Wisdom teeth are never replaced.
- Second molars are replaced in some cases and not others; an implant there is useful but not essential.
- Teeth from the first molar forward almost always should be replaced, because they carry the chewing and they show when you smile.
That conversation happens before the extraction, because it changes what we do at the extraction.
Some extractions are better done by an oral surgeon:
- Patients who need intravenous sedation or general anesthesia
- Teeth sitting against the nerve
- Medical situations that call for a hospital setting
We refer those and coordinate the rest.
Planning the space before the tooth comes out
We usually take a CT scan beforehand to see the root, the bone and any risks, and to plan what happens next.
An implant the same day. When the tooth is to be replaced and the site is suitable, placing the implant at the time of extraction means one surgery and one healing period. Whether that is possible depends on the bone, on infection, and on whether it is a front tooth where appearance drives the plan. A temporary crown on the new implant is sometimes possible, again depending on the tooth. Our implants page has the detail.
A bone graft. When an implant is not placed immediately but the tooth will be replaced later, we place bone graft material in the socket to preserve the bone that would otherwise shrink away over the following months. Most grafts are simple socket preservation. Occasionally, when infection has already destroyed bone or the site needs building up, we use a more involved graft with a reinforced membrane. A graft does not guarantee there will be enough bone for an implant later, but it makes it much more likely, and the bone is of better quality.
No graft. Patients who are sure the tooth will never be replaced can skip the graft. We confirm that choice with you before the visit.
Simple and surgical extractions
Most extractions are simple: the tooth is loosened and lifted out in one piece. Some are surgical: a tooth broken at the gum line, a tooth with curved or widely spread roots, or one fused to the bone may need to be divided into sections and removed piece by piece, sometimes with a small amount of bone smoothed around it and a stitch or two afterward. Both are done with local anesthesia in the office. The CT scan usually tells us in advance which kind yours will be, so that the appointment is planned for it.
Tell us about your health
A few things change how an extraction is planned:
- Blood thinners, including aspirin and the newer anticoagulants, affect bleeding and are managed with your physician, usually without stopping them.
- Medicines for osteoporosis or certain cancers that act on bone can affect how a socket heals, and we need to know about them before any tooth is removed.
- Diabetes, heart conditions, artificial joints and recent surgery can call for precautions or antibiotics beforehand.
Bring your medication list, and we coordinate with your doctor where needed.
What the visit is like
- Step 1 of 5 Anesthesia
A topical gel first, then the local anesthetic, given slowly with a technique and anesthetics chosen so that the injection itself is barely noticed. We use enough to make the area completely numb, and we check before starting.
- Step 2 of 5 The extraction
You feel pressure and movement as the tooth is loosened, not pain. Some teeth come out simply; others take more work. Bring headphones; most patients listen to music or a podcast.
- Step 3 of 5 Cleaning and grafting
The socket is cleaned. If a graft is planned, the bone material goes in, usually with a membrane over it, and a few stitches close the site.
- Step 4 of 5 Instructions and prescriptions
Written aftercare, and prescriptions as the case calls for: often an antibiotic when a graft has been placed, and pain medication for the first days.
- Step 5 of 5 Follow-up
When a non-dissolving membrane has been used, it and the stitches are removed about four weeks later, a five-minute visit that needs no anesthesia.
Recovery
- Pain after an extraction is usually mild and well controlled by the medication.
- Most patients can return to light work the next day.
- For a few days avoid strenuous exercise, direct sun and radiating heat, which increase bleeding and swelling.
- Eat soft, cool food on the other side at first.
- Do not smoke, use a straw, spit forcefully or rinse hard for the first days, because disturbing the blood clot in the socket leads to a dry socket, which is painful and slow to heal.
- Keep the area clean gently.
- If swelling increases after the second day, you develop a fever, or the pain gets worse rather than better, call us.
Afterward
Once the site has healed, the plan you made before the extraction takes over: an implant placed into the grafted bone, a bridge, or, for several missing teeth, a denture. If you chose not to replace the tooth, we keep an eye on the neighbors at your regular visits, because teeth beside a gap can drift over time.
Frequently asked questions
Does having a tooth pulled hurt?
You should feel pressure and movement, not pain. We numb the area thoroughly, beginning with a topical gel and giving the anesthetic slowly, and we do not start until the tooth is completely numb. If you feel anything sharp, you raise a hand and we add more.
How long is the recovery?
Most patients are back at light work the next day, as long as it is not heavy physical work; a desk job in air conditioning is fine. Avoid exercise, direct sun and radiating heat for a few days. Soreness is usually mild and controlled by the medication we prescribe.
Do I need a bone graft?
If you plan to replace the tooth with an implant, usually yes. A graft placed in the socket at the time of extraction preserves the bone that would otherwise shrink away, and gives the implant a better foundation. If you are certain the tooth will never be replaced, a graft is optional.
Can the implant go in the same day?
Often, when the bone is sound, there is no significant infection and the plan is to replace the tooth. It saves a surgery and a healing period. Whether a temporary tooth goes on it the same day depends on the tooth, the bone and the bite.
Does every extracted tooth need replacing?
No. Wisdom teeth are not replaced. Second molars are replaced in some cases and not others. Teeth from the first molar forward almost always should be, because they matter for chewing and they show.
What should I eat afterward?
Soft, cool foods for the first day or two, chewing on the other side. Avoid straws, smoking, spitting and vigorous rinsing for the first days, which can disturb the clot and lead to a painful dry socket. We give you written instructions before you leave.
Sources
Professional guidelines and peer-reviewed reviews this page draws on.
- Avila-Ortiz G, Elangovan S, Kramer KWO, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: a systematic review and meta-analysis. Journal of Dental Research. 2014;93(10):950-958. DOI
